103 CHAPTER 4 DOUBLE ENTITY, DOUBLE JEOPARDY Introduction Because of the unique health care responsibility the midwife has to a double entity (the mother and baby) the midwife has to balance or maximise what is in the interests of both. In the following pages the midwife's professional obligations to this double entity, in particular about infant nutrition, will be described. In order to fulfil these obligations and achieve what is morally right the midwife needs to act to provide benefits and prevent harms to both mother and baby. Benefits include giving accurate advice to the mother about establishing and maintaining breastfeeding. Preventing harms includes explaining about the harmful effects on breastfeeding and the potential to harm the baby if the mother chooses to feed her newborn baby with artificial formulae. Because the harms of artificial formulae are so demonstrably bad, I believe the midwife should use persuasion and offer positive alternatives to artificial formulae such as wetnursing or human milk banking. This chapter will also focus on autonomy and paternalism which may be in conflict when there are competing claims between benefits to the woman and the prevention of harms to the baby. Some women choose to exclusively artificially feed their newborn. The following extract from an Australian Women’s news weekly lists some of the reasons one woman gave for choosing artificial formulae:
Transcript
103
CHAPTER 4
DOUBLE ENTITY, DOUBLE JEOPARDY Introduction
Because of the unique health care responsibility
the midwife has to a double entity (the mother
and baby) the midwife has to balance or maximise
what is in the interests of both. In the
following pages the midwife's professional
obligations to this double entity, in particular
about infant nutrition, will be described.
In order to fulfil these obligations and achieve
what is morally right the midwife needs to act to
provide benefits and prevent harms to both mother
and baby. Benefits include giving accurate advice
to the mother about establishing and maintaining
breastfeeding. Preventing harms includes
explaining about the harmful effects on
breastfeeding and the potential to harm the baby
if the mother chooses to feed her newborn baby
with artificial formulae. Because the harms of
artificial formulae are so demonstrably bad, I
believe the midwife should use persuasion and
offer positive alternatives to artificial
formulae such as wetnursing or human milk
banking.
This chapter will also focus on autonomy and
paternalism which may be in conflict when there
are competing claims between benefits to the
woman and the prevention of harms to the baby.
Some women choose to exclusively artificially
feed their newborn. The following extract from an
Australian Women’s news weekly lists some of the
reasons one woman gave for choosing artificial
formulae:
104
A new father can feel rejected because of the time the mother spends breastfeeding... one drawback was having to watch what I ate as some food tainted the milk ...some women find large heavy breasts uncomfortable and unattractive and consequently are unable to exercise.163
Some breastfeeding women may ask the midwife to
give the baby artificial formulae during the
night so that the woman can have an uninterrupted
or good night's sleep. A moral dilemma for the
midwife is created between the duty to prevent
harm to the baby and the duty to respect the
wishes of the mother.
James McKenna, an American Anthropologist posits
the theory that separation of infants from
parents is abnormal and that co-sleeping improves
sleeping patterns of infants and mothers.164 He
also suggests a link between co-sleeping and
prevention of Sudden Infant Death Syndrome [SIDS]
so that removal of babies to the nursery may be
another harm to the newborn.
An attempt will be made to make a reasoned case
for persuading the woman who does not wish to
breastfeed, to change her mind about her choice
of infant nutrition. Because there is a need to
provide an atmosphere of freedom of choice,
specific methods of communication will be
described. The ways in which the midwife can
persuade the woman to change her decision may be
limited by the woman's depth of knowledge and
beliefs. The importance of examining these limits
will be explored.
163 Stewart, D. l992. ‘Why I’m a bottle-feeding mum.’ The Australian Women’s Weekly. Sydney: ACP Publish- ing Ltd. February Soapbox
...Affirming the right of every child and every pregnant and lactating woman to be adequately nourished as a means of attaining and maintaining health;
165 Lewinski, C. l992. ‘Nurses' knowledge of breast- feeding in a clinical setting.’ J. Hum Lact., 8 (3) 142-148 cited in Update. l1:10 p 9
106
Recognising that infant malnutrition is part of the wider problems of lack of education, poverty and social injustice;... Conscious that breast-feeding is an unequalled way of providing ideal food for the healthy growth and development of infants; that it forms a unique biological and emotional basis for the health of both mother and child; that the anti-infective properties of breastmilk help to protect infants against disease; and that there is an important relationship between breast-feeding and child-spacing;
... Recognising further that inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries, and that improper practices in the marketing of breast-milk substitutes and related products can contribute to these major public health problems; ... Appreciating that there are a number of social and economic factors affecting breast-feeding, and that, accordingly, governments should develop social support systems to protect, facilitate and encourage it, and that they should create an environment that fosters breast- feeding, provide appropriate family and community support, and protects mothers from factors that inhibit breastfeeding. 166
How the midwife can act to enhance professional,
public, local and national bodies to promote
breastfeeding will be included later in this
chapter.
1. The Midwife And Her Professional Obligations
The professional autonomy of the midwife, as the
primary carer for most women and their newborn
babies in this country, rests with the midwife
maintaining credibility as the expert designated
to give the best advice to women in regard to
infant nutrition. Professional autonomy entails
166 [WHO]World Health Organization. l981. International Code of Marketing of Breast-milk Substitutes. WHO/MCH/90.1 (Annex 2 p.47 )
107
increased reliance on one's own judgment, and
correspondingly the midwife is morally
responsible for the consequences of her practice.
If the midwife believes that she is acting in the
woman's best interests by enabling her to have a
good night's sleep then she may consider her
action [giving the baby artificial formulae] to
be morally defensible. The benefit of a good
night's sleep should not, however, have
sufficient precedence over the known harmful
consequences of a baby receiving artificial
formulae. When the midwife gave a formula to the
baby of a breastfeeding woman without her
consent, then she was acting paternalistically.
Paternalism and its implications will be
discussed in the next section.
The midwife was also unprofessional because her
judgement was marred by a lack of current
knowledge. As Tom Beauchamp and James Childress
put it:
In professional relationships the argument is that a professional has superior training, knowledge and insight and is in an authoritative position to determine what is in the patient's best interests. The professional is like a parent when dealing with dependent and often ignorant patients.167
In this case the midwife has mistakenly used her
authority and consequently abused the dependent
status of the woman to whom she has a duty of
care.
167 Beauchamp, T.L. & Childress, J.F. l989. Principles of Biomedical Ethics. New York: Oxford University Press. pp 212-213
108
When the midwife gives artificial formulae to the
baby without the consent of the woman who has
chosen to exclusively breastfeed her baby, the
midwife not only harms the process of
breastfeeding, but may cause short and long term
harm to the newborn baby. Her knowledge is
inadequate and may even border on culpable
ignorance. The confusion between what is
beneficial for the mother and what is beneficial
to the baby is complicated by the midwife's lack
of knowledge about the benefit of breastfeeding
in relation to sleep, and patterns of
breastfeeding in the newborn. McKenna
demonstrates on film that babies left co-sleeping
with their breastfeeding mother will actually
knock on the breasts when seeking a feed and
mimic the mother’s movements during her sleep168.
In l994 Jan Edwards recent President of the Board
of the Australian Lactation Consultants
Association [ALCA] in a personal communication
re-affirmed that the practice of giving
artificial formulae to babies of breastfeeding
mothers, still continues.
Placing the baby in the nursery limits easy
access of the mother to her baby and consequently
her ability to control what is fed to her baby.
Commisso, referred to in Chapter One stated that:
it is usually women having their first baby who are unable to resist the persuasion to place their baby in the nursery overnight.169
The failure of the woman to sleep through the
night may be seen to reflect poorly on the
midwife's perception of what a good midwife does
168 Harris, H. l994 President of ALCA Melbourne:
169 Commisso, loc. cit.
109
in caring for the women in her care. The woman
also may have unreal expectations about a good
night's sleep. The need to prove that the woman
had a good night's sleep may be a more powerful
influence on the way the woman and the baby are
managed, than whether the woman was assisted in
her desire to establish breastfeeding.
It is true that the woman who has recently given
birth to a baby is tired. However, for the
newborn the urge to be fed (having recently been
removed from a continuous supply of nutrients in
utero) usually requires a range of frequency of
feeds from one or even up to ten or more feeds
(commonly referred to as cluster feeds) in the
next twenty four hours, with a similar pattern
for some weeks.
Most up to date midwives recognise this factor as
being different from what was traditionally
thought and accommodate the difference. Provided
there is no maternal impediment, such as rare
congenital lack of breast tissue, most healthy
normal women can provide human milk for their
newborn. As a leading textbook on the subject of
breastfeeding states:
It is advisable for numerous reasons to feed young infants whenever they indicate a need... In general young infants, especially newborns, have very irregular feeding intervals. They may feed at unevenly spaced intervals from 6 to 12, or as many as l8 times in a 24-hour period ...Mothers, [midwives, the general public and close relatives], may need reassurance that this early phase of very frequent feeding is likely to settle into more predictable routines as lactation is established.170
170 Royal College of Midwives [RCM] l991. Successful Breastfeeding. New York: Churchill Livingstone. p 33
110
The quality of sleep of the newly delivered
mother may also be improved by breastfeeding at
night.
...There is a suggestion that dopamine receptors in the brain mediate sedation. ...this may account for the often reported and observed sleepiness that women experience when they breastfeed. 171
The midwife is also lacking in knowledge about
the effects of giving a bottle of artificial
formulae, including its harmful effects on the
baby as well as its interference with the process
of breastfeeding. This interference with
drainage, the sine qua non of successful
breastfeeding sometimes results in painful
blockage, engorgement, inflammation and abscesses
of the breasts.
2. The Obligations Of A Professional Not To Harm.
The midwife has a professional obligation to
prevent harm to the baby, and to do so, she must
be up to date in her field of expertise.
Peter Singer and Helga Kuhse give an instructive
parallel example of responsibility for preventing
harm:
...If I am standing on the beach while someone drowns in the surf fifty metres
171 ibid.
111
away, I will not be morally responsible for the death if, concentrating on a game of beach cricket, I fail to notice the person signalling for help. Even if I did notice the signal, but was unable to help because I cannot swim a stroke and there was no one else who could be summoned in time, I will not be responsible. If, however, I noticed the signal and could easily have carried out the rescue, but refrained from doing so because I didn't wish to interrupt my sunbathing, I bear considerable moral responsibility for the death. If I happen also to be a lifeguard and was on duty at the time, my moral responsibility for refraining from rescuing the drowning person is greater still. Moral responsibility arises only when we have some control over our actions in a situation, and it is strengthened when we have a specific duty that is relevant to what is happening.172
An analogy can be drawn with the mother who
wishes to artificially feed her baby but knows
nothing about the harms of artificial formulae.
Her baby is the drowning person and the mother is
the person who cannot swim. The motive or intent
of the mother who is lacking knowledge, is
morally different however, from the midwife who
lacks knowledge. This midwife is a professional
who ought to have current knowledge, and who has
not bothered to update her knowledge. Her
position is similar to the lifeguard who was on
duty but refrained from rescuing the drowning
swimmer. However, this midwife is even more
irresponsible because she has not maintained her
skills.
The lifesaver, who is able to swim but makes no
attempt to save the drowning person is also
similar to the midwife who has the knowledge and
fails to prevent the baby from receiving
formulae. But there is a difference between
172 Kuhse, H. & Singer, P. l985. Should the Baby Live? Oxford: Oxford University Press. p 84
112
those midwives who know about the harms of giving
formulae and do nothing to prevent the giving of
the bottle and those who do not know about the
harms of giving formulae and still give a bottle
of formula to the baby. The result in each case
is that the baby receives a bottle of formula.
Both of the midwives are wrong but in different
ways.
Neither of these midwives, however, should be
excused from the moral obligation to have current
knowledge about breast feeding and the moral
obligation to avoid harming those in her care.
The midwife has, a similar professional
responsibility to the lifeguard, not only to have
knowledge, but to use that knowledge in
preventing harm. The midwife has as stated later
in Kuhse and Singer173 ‘some control over her
actions and has a specific duty that is relevant
to what is happening’.
The midwife who knows the harms and still gives
formulae to the baby, may have weighed up harms
to herself. In practice it can be difficult to
persuade colleagues that giving formulae is
harmful. The resistance to the idea may make the
midwife extremely uncomfortable. The knowledge-
able midwife will often be faced with the
decision whether to act in the face of risks to
herself. Her career may suffer if she attempts
to carry out practices which are in conflict with
a superior who is not as knowledgeable.
For example a student will begin to give
information to a woman about the benefits of
173 ibid.
113
breastfeeding and the harms of artificial
formulae. A midwife who is out of date may
challenge the student and change the student's
management in front of the woman. The student
becomes distressed for two reasons, firstly the
knowledge imparted by the midwife is wrong and
even damaging, and secondly the student's
credibility is diminished.
As the student's clinical supervisor I usually
debrief the student and the midwife (separately)
in order to bridge the gap between current
knowledge and out of date practice. On occasions
following this debriefing the out of date midwife
may victimise the student. Student midwives who
are powerless and often in a vulnerable position,
become distressed because they are stopped by
intransigent, out of date midwives, from teaching
the mother about correct breastfeeding practices.
I also experienced moral distress when the out of
date midwife projected her anger at me. A result
of what this midwife perceived as interference
with her practice or agency protocols, included
(as the midwife happened to be in a position of
authority) threatening the placement of
university students. The attempt to prevent the
giving of formulae or promoting successful
breastfeeding may result in too great a harm to
the student, the clinical supervisor and the
university. If in order to avoid conflict or
victimisation, compliance with the out of date
midwife follows, then intolerable guilt leading
to moral distress may occur.
Kuhse and Singer's example, outlined above, could
be extended to include a situation where the
lifesaver may resist saving a life because she
might drown in rough seas. If the midwife or the
114
lifesaver does not act, in the face of rough seas
or risks, are they morally culpable? Singer (as
cited in Beauchamp and Childress) contends that:
...we have an obligation to assist ...if it is in our power to prevent something bad from happening, without thereby sacrificing anything of comparable moral importance, we ought, morally, to do it.174
While some actions can be taken and ought to be
taken there may be cumulative effects if carried
out too often. That is the person undertaking
the action may need to conserve energy so as not
to be incapable of acting at other times.
Benefits accrue from the judicious use of bravery
rather than constantly setting unrealistically
high standards.
The student or midwife who takes risks on a daily
basis may eventually resign due to cumulative
stress or burn-out, as a result of conflict.
Alternatively, a midwife may remain in the health
system, but become fearful of change and resist
efforts to introduce new knowledge or practices.
But sometimes by persisting she may find that
there are times when the power of others to cause
harm has diminished. The previously mentioned
threat to student placement was negated three
months later when complaints from women to a
higher authority resulted in the re-education and
subsequent re-deployment of the out of date
midwife.
Sometimes the conflict itself brings about a
change in attitude and the risk of harm
174 Singer, P. l979. Practical Ethics. Cambridge: Cambridge University Press pp 168 ff cited in Beauchamp and Childress Principles of Biomedical Ethics New York Oxford University Press p 198.
115
disappears. As stated by John Stuart Mill in On
Liberty:
Truth, in the great practical concerns of life, is so much a question of the reconciling and combining of opposites, that very few have minds sufficiently capacious and impartial to make the adjustment with an approach to correctness, and it has to be made by the rough process of a struggle between combatants fighting under hostile banners. 175
The first step in a process of bringing about
change described by Kurt Lewin included a concept
similar to Mill’s description of a rough process.
Lewin described promoting situations which
‘unsettle the established modes of behaviour’ and
he termed this unfreezing. If in response to
this unfreezing, change occurs, then Lewin
suggests locking the new behaviour into place by
means of providing benefits such as praise and
rewards. This latter process he termed
refreezing.176
If the knowledgeable midwife is unable to
persuade the woman or her colleagues then she may
need to use alternative strategies such as
Lewin’s model for overcoming resistance to new
knowledge or practice. In order to improve the
knowledge or correctness of the out of date
midwife the student or midwife may have to accept
the lack of minds ‘sufficiently capacious or
impartial to make adjustments’.
Moral distress may be an outcome for the student
but the conflict itself may bring about a change
in attitude of the out of date midwife. By
175Mill, J.S. l948. On Liberty and Considerations on Representative Government. McCallum R.B. (Ed.) Oxford: Basil Blackwell p 42
176 Stoner, J.A. Collins, R.R. and Yetton, l985. Management in Australia. New Jersey: Prentice-Hall
116
accepting the rough process of a struggle then
the student midwife may avoid intolerable guilt
and pursue correct practice.
It should be possible to carry out our obligation
to assist without sacrificing anything of
comparable moral importance as Singer, cited
earlier, contends. If the student midwife or
clinical supervisor are prepared to endure
uncomfortable feelings then moral distress may
not necessarily be an outcome.
The intransigence of her colleagues, let alone
the resistance of the mother to knowledge about
the harms of artificial formulae to the baby, and
the powerful force of industrial marketing, place
at times, seemingly insurmountable barriers in
the way of enhancing correct breastfeeding
practices.
But if the midwife gives the woman up to date
information and prevents exposure to
misinformation from intransigent midwives she
enhances successful breastfeeding. By educating
the woman about the harms of artificial formulae
the midwife also improves the woman’s’ decision
making ability and as a result may avoid harms to
the baby. By avoiding harms the midwife has also
respected the woman’s autonomy.
3. Autonomy And Paternalism Autonomy, (the literal meaning of which is self-
rule), or the idea of personal autonomy as an
extension of self determination by the individual
is, as described in Beauchamp and Childress;
a personal rule of the self while remaining free from both controlling interferences by others and personal limitations such as
pp 452-453
117
inadequate understanding that prevent meaningful choice.177
women breastfeeding at three months.179 The figures
give some credence to the view that most women
choose to at least initiate breastfeeding.
Usually the decision is made by the mother about
the method of infant feeding but many factors
play a part in influencing that decision.
Attitudes, beliefs, knowledge and experience of
either partner, relatives, doctors, midwives and
friends, may contribute to whether the choice is
a strongly held desire of others or the
autonomous wish of the mother.
If the woman chooses to breast feed, then the
midwife should act to respect that woman's wishes
and prevent harm to that process. The midwife is
not acting to respect the woman's autonomy when
she gives artificial formulae to the baby without
the consent of the woman who has chosen to
177 Beauchamp, op. cit., p 72
178 ibid., p 71
179 HDV op. cit., p 127
118
exclusively breastfeed her baby. A midwife who
does this is acting paternalistically if she does
it because she thinks it will be in the woman's
best interests.
The root meaning of paternalism (after the
writings of Immanuel Kant and Mill) is; `the
principle and practice of paternal
administration; government as by a father; ...in
the same way a father does for those of his
children’.180
According to some definitions, a paternalistic
action, whatever its form, necessarily infringes
autonomous choice and on that basis is not
usually morally justifiable. Alternatively, some
proponents of paternalism state that paternalism
may be morally justified when it involves
overriding a person's wishes in order to provide
benefits or to avoid harms.
For example, a person who has a severe infection
may object strongly to being injected with life
saving antibiotics in spite of being adequately
informed. The objections based on fear of pain
ought to be considered of lesser importance than
actions to prevent death. In order to act in the
patient’s best interests a judgement about
competence may need to be made. This may involve
appeals to a higher authority (Medical Director
or the Law) which may then rule the patient
incompetent on the basis of, as argued by
Beauchamp and Childress, ‘the harms preventing
from occurring outweigh the loss of
independence’. 181. Weak paternalism would be
justified if this person was suffering from an
180 Beauchamp, op. cit., p 212
119
illness likely to cause death, for example
meningitis. It is likely that such a patient
would be disorientated from fever and therefore
has a degree of compromised ability to make a
judgment. With an involuntary patient some form
of restraint would need to be used in order to
give the injection.
Paternalism is sometimes described as Weak
paternalism if it is carried out in the interests
of someone (in this case, the woman) who is non-
autonomous. Included in a description by
Beauchamp and Childress of a non-autonomous
person is one whose consent is ‘not adequately
informed or has compromised ability’.182
In weak paternalism one has the right to prevent
self-regarding conduct only when it is
substantially non-voluntary or temporary
intervention is necessary to establish whether it
is voluntary or not.183
The autonomy of the woman who does not know about
benefits of breastfeeding or harms of artificial
feeding would be compromised to some extent. Any
decision about infant nutrition by this woman
would be described as substantially non-
autonomous. When the midwife enhances this
woman's knowledge she empowers her to make an
informed decision which restores to her an
increased degree of autonomy.
The midwife who acts to avoid harms to a woman
when there is a degree of compromised ability
(because the woman is not adequately informed
181 ibid.,p 219
182 loc cit p 218 183ibid
120
about the choice of nutrition of her baby) is
using a weak paternalistic intervention. Making
an uninformed decision which could harm her baby,
may cause emotional distress to the woman.
In order to justify the argument that the woman's
autonomy is being jeopardised, it is useful to
realise that there is a potential to emotionally
harm the woman. If the woman values her newborn
baby's health, finding out about the harmful
consequences of artificial formulae, after the
event, may result in outrage. Her distress may
be even greater if she discovered that the
knowledge about harmful consequences had been
negligently withheld. Hence the midwife's
beneficent intervention to enhance the woman's
knowledge, and prevent psychological harm to the
uninformed woman is justified weak paternalism.
.31 Information Giving & Informed Consent
The most relevant meaning of consent includes a voluntary uncoerced decision, made by an autonomous person on the basis of adequate information and deliberation, so that they are able to reject or accept a course of action that will affect him or her184
Establishing whether the woman has made an
authentic decision `free of coercion or
controlling influence of others' would be
ascertained by the midwife during the
decision making or interview process. If
the woman is to choose autonomously about
the method of feeding her baby, she has to
act in accordance with an informed plan.
184 Gillon, R. l986. Philosophical Medical Ethics Brisbane: John Wiley & Sons p 113.
121
The notion of informed consent is congruent
with the concept of an informed plan.
The midwife should give accurate and
complete information about the benefits of
breastmilk and the harms of artificial
formulae and encourage the woman to make a
choice based on material information.
Material information is what the woman
regards as worth knowing about, even if it
will not causally affect her decision about
whether to choose breastfeeding or
artificial feeding. For example, if there is
a family history of asthma, then the
allergenic properties of cow's milk formula
would be material.
A sample consent form listing the harms of
artificial formula was included in the l994
Victorian Government Health and Community
Services Promoting Breastfeeding
Guidelines.185
In the case of the woman who chooses to
artificially feed her baby, the midwife may
suspect that she is not adequately informed.
The midwife should be justified in informing
her of the benefits of breastfeeding and the
harms of artificial feeding. Some women who
are not adequately informed may already have
another child or children with asthma,
diabetes or heart disease, or a strong
family history of disease. This history is a
still more conclusive justification for
persuading the woman to breastfeed. A
secondary effect of this persuasion if
185 Health and Community Services l994. Promoting Breastfeeding Victorian Breastfeeding Guidelines Melbourne: Victorian Government Publication. Appendix 1
122
successful, would be prevention of harm to
the baby, who is entirely non-autonomous.
As the following recommendation from the
Ministerial Review of Birthing Services in
Victoria demonstrates, women have recently
expressed the need to take control of their
own birthing experience (which may include
breastfeeding):
All hospitals and care givers in private practice should consider developing birth plan forms, to be used as a standard part of antenatal care to record the pattern of care agreed to in discussion with women and their partners. 186
The emphasis should therefore be on
respecting the woman's autonomy and not
on the midwife's traditional practice of
making independent judgements about the
woman's care.
Collection of relevant data and
consultation with the persons in her
care, peers and other health carers are
an inherent part of maintaining standards
of midwifery care. By consulting the
woman about her care, the midwife not
only respects the woman's autonomy, but
enhances the achievement of the best
consequences overall. This includes
consequences which are in the best
interests not only of those in her care,
but also of her profession, her employer
and the wider community.
.32 Self-determination in Midwifery Practice
186 HDV op cit p 55
123
Apart from the standard of midwifery
practice which urges the midwife to maintain
knowledge and the skills required to achieve
excellence in midwifery practice, the
midwife is instructed to: ‘use a problem
solving approach to provide health education
on an individual basis’.187
One particular problem solving approach
which has been universally used in nursing
practice, is named the Nursing Process.
The Nursing Process consists of five steps - assessment, analysis/nursing diagnosis, planning implementation and evaluation, and is analogous to the [informal] problem solving process used by nurses since Florence Nightingale 188
By using the Nursing Process in a birth
plan format recommended by the HDV Study
Group mentioned earlier, the midwife
incorporates one of the basic tenets of
autonomy, that is self determination.
The midwife involves the woman in
planning the care of herself and her
baby.
While Birth Care Plans have been taken up
by many women and some agencies in the
last decade, the content is mainly
focussed on conduct of labour and pain
relief methods. It is my contention that
this plan should dedicate a large
proportion of the content to
187Olds, S. London, M.L. Ladewig, P.W. l992. Maternal
Newborn Nursing. 4th Edition Sydney: Addison-Wesley p 23, 188 ibid., p 25
124
breastfeeding. A nine page,
predominantly check list style lactation
plan by Wellstart International can be
found in Riordan Appendix H 189. This
broadly based plan encourages the midwife
and the woman to examine and record a
history of medical, family, nutrition,
lifestyle habits and a past and present
breastfeeding history of the woman.
Early decisions about infant nutrition
feeding and preferences of the mother are
established. While nine pages may seem
time consuming for the mother the
principle of autonomy is met particularly
if the woman enters the data.
If an interview for the purpose of taking
a lactation history is followed by and
coincides with visits to the midwife in
the antenatal period, then the
opportunity for the introduction to a
valuable education program can be
initiated.
In the analysis phase of the nursing
process the midwife determines the entry
knowledge of the woman and then makes a
diagnosis. One example of a midwifery
diagnosis is knowledge deficit which
could be used to describe the status of
the woman who has insufficient knowledge
about infant nutrition. The midwife then
proceeds to implement an education
program which should involve a formative,
cumulative and summative evaluation of
the woman's understanding. The midwife
uses a series of balances and checks to
ensure substantial understanding.
189 Riordan, op cit., pp 657-666
125
.33 Substantial Understanding and Weak Paternalism
Substantial understanding according to
Faden and Beauchamp is:
somewhere between adequate and full understanding ...effective communication needs to be used to facilitate this understanding.190
Successful communication usually results
from the use of a variety of communication
techniques such as open ended questions,
active listening (clarifying, focusing, and
paraphrasing) and passive listening (eye
contact, open stance and congruent facial
expression).191
When the midwife provides the woman with up
to date and accurate knowledge as well as
ensuring substantial understanding then the
midwife maintains optimal standards of
midwifery practice. The midwife is able to
act in the woman's and baby's best
interests, because the midwife has provided
the woman with the opportunity to make the
best choice for her baby. The midwife has
disclosed information, assisted the woman to
comprehend the information about the risks
and outcomes of infant nutrition, and
ensured voluntariness, that is she has not
coerced or unduly influenced the decision.
She has respected the woman's autonomy and
190 Faden, R.R. & Beauchamp, T.L. l986. A History and Theory of
Informed Consent. New York: Oxford University Press. p 305 191 Bolton, R. l991. People Skills: How to Assert Yourself, Listen to Others, and Resolve Conflicts. Australia: Simon Schuster Parts One and Two
126
empowered her to give informed consent or to
make an informed choice.
Justified weak paternalistic interventions involve respect for autonomy, and yet may initially mean disregarding consent.192
Consent may be given, however, following a
full explanation of benefits or harms. In
other words decision making capacities are
enhanced.
Weak paternalism is justifiable in so far as consent to the interference would be forthcoming were the subject's decision-making capacities restored.193
An example of improved decision making
capacities and the relationship to justified
weak paternalism was explicated in the
preceding pages.
.34 Strong Paternalism
As stated earlier 80% of women in Victorian
Hospitals choose to initiate breastfeeding.194
Described in the first Chapter of this
thesis were some of the factors which may
contribute towards the decline of women
maintaining breastfeeding at three months to
57%. One of these factors was giving of
artificial formulae to babies of
breastfeeding women which resulted in
interference with prolactin release and
drainage of the breasts. The subsequent
192 Beauchamp, op. cit., p 247 193 Young, R. l986. Personal Autonomy: Beyond Negative and Positive Liberty. London: Croom Helm. p 64 194 HDV, op. cit., p 127
127
outcome of this effect usually is a poor
milk supply leading to the abandonment of
breastfeeding.
Similar figures in a Canadian study
demonstrated a breastfeeding initiation rate
of 80%, but in spite of the WHO
recommendation to breastfeed at least for 6
months, exclusive breastfeeding rates at 6
months were 25%.195
A claim of justified paternalism, that is,
acting in the breastfeeding woman's best
interest to provide a good night's sleep,
can be negated by anecdotal evidence that
breastfeeding women generally sleep equally
well when access to their babies is
unrestricted at night and rooming-in is
increased. 196 197
The conflict then, is between perceived
beneficence (one ought to do good and ensure
a good night's sleep) and failing to respect
the woman's wishes to exclusively
breastfeed, (overriding respect for
autonomy) by giving the baby of a
breastfeeding woman artificial formulae
without consent.
The action-guiding moral principle, respect
for autonomy, has here been wrongly
overridden by the principle of beneficence.
195 Ellis, op. cit., p 626. 196 Walker, B. l986. Survey of antenatal women's expectations, and postnatal women's actual patterns of sleep in the postnatal period. Melbourne: Mercy Hospital for Women. Unpublished 197 Waldenstrom, U. & Swenson, A. l992. ‘Rooming-in at night in the Postpartum Ward.’ Midwifery. UK: Longman Ltd. 7:82-89
128
Paternalistic action by the midwife is
unjustified when it is based on mistaken
beneficence.
Any action which overrides a substantially
autonomous or voluntary decision, would be
defined as strong paternalism. Advocates or
defenders of Strong paternalism, hold that
‘it is sometimes proper to intervene in
order to benefit a person even if that
person's risky choices are informed and
voluntary’.198
The woman, who has had a substantial degree
of autonomy restored through good
communication and education, may persist in
her decision to artificially feed her baby
because it prevents distress to herself. In
spite of warnings about harms to the baby
the woman may choose to ignore the risks.
In spite of the availability of alternatives
such as human milk banking or wet nursing
the woman may still wish to artificially
feed her baby. Is the harm to the baby
serious enough to warrant limiting the
woman's freedom? Does the baby have a right
to the woman's body or at least to correct
nutrition in the form of human milk? Can
the woman be incarcerated and forced to
give her baby breastmilk?
In an often quoted example John Stuart Mill
states:
If either a public officer or any one else saw a person attempting
198 Beauchamp, op. cit., pp 218-219
129
to cross a bridge which had been ascertained to be unsafe, and there were no time to warn him of his danger, they might seize him and turn him back without any real infringement of his liberty: for liberty consists in doing what one desires, and he does not desire to fall into the river.199
In the situation described earlier on page
119 the patient refused an injection to save
his life. On the basis of compromised
ability to make a judgment and the avoidance
of harms, his autonomy was overridden and
using restraint a life-saving injection may
be forcefully given. This situation could
be analogous to, as quoted in Mill ‘seizing
him and turning him back’ because if he was
competent he may prefer to have the
injection or be prevented from dying.
Overriding his autonomy may have been
infringing liberty, but in the end the
saving of his life may have been what the
patient genuinely desired.
But if the condition for the patient was not
life threatening then a case could be put
for respecting his autonomy by warning of
danger but not forcing him to have the
injection. I agree with Mill when he goes
on to say;
Nevertheless, when there is not a certainty, but only a danger of mischief, no one but the person himself can judge of the sufficiency of the motive which may prompt him to incur the risk, ... he ought, I conceive, to be only warned of the
199 Spitz D.(Ed.) l975. On Liberty John Stuart Mill Annotated Text Sources and Background Criticism New York: W.W. Norton & Company P 89
130
danger; not forcibly prevented from exposing himself to it.200
The woman who persists in giving her baby
artificial formulae may have very strong
inner compulsions or fears which in spite of
substantial explanations, cannot be
overcome. She may also be compelled to
return to work and be unable to breastfeed
for this reason unless of course the work
situation was conducive to breastfeeding.
The importance of her reasons is known only
to herself.
The woman should be warned of the dangers of
artificial formulae. Coercing her to
breastfeed would not only be impractical,
but may be viewed as strong paternalism, at
least in so far as it relates to her own
interests. It would be difficult to justify
paternalism on these grounds. There is,
however, another issue: that of harm to the
baby.
4. Prevention Of Harm To The Baby
Mair, a nurse-lawyer drew attention to the
obligations of the health care professionals to
prevent harm to a child when she wrote about a
successful Victorian damages claim of a child,
against his mother while a fetus:
...as well as giving consideration to the likely effect upon the pregnant woman, they [the Health Care Professionals] need to consider the possible effect on her existing unborn child and to others who may be subsequently born to her. The duty of care will arise if it is reasonably foreseeable that acts or
200 ibid p 89
131
omissions of the health professional will expose a prospective plaintiff to an unreasonable risk of harm.201
The claim of a fetus while a prospective
claimant may be analogous to that of the
newborn baby. A child may make claims about
forseen damages, as a consequence of receiving
artificial formulae while a newborn baby.
It could be argued that the midwife needs to
consider the forseeability of possible harms to
the newborn baby when advising the mother about
infant nutrition.
The defendants argued in the Victorian case
that the plaintiff was not a legal person and
that the fetus and her mother were essentially
one personality. The judge disagreed and the
child was awarded damages against the negligent
driving of its mother. D. Brahams adds in a
paper about this issue that: ‘in Britain
concerns about pregnant women who engage in
hazardous activities eg. smoking, drinking have
not had much practical impact’.202 Brahams
elaborates further that:
In England at least a fetus must take its mother as it finds her ...it is the mother's rights and interests that will prevail in law if the mother wishes. ...Different attitudes have been expressed in the USA, where women have been constrained and confined with a view to protecting their unborn child from their mother's unsatisfactory lifestyle.203
201 Mair, J. l991. ‘Foetal Life and a Legal Duty of Care.’ ACMI Journal. Dec P 13
202 Brahams, D. l991. ‘Australian mother sued by child in utero.’ The Lancet vol 338 no 8766 l4 September pp 687-688 in MIDRS. Midwifery Digest. (Mar l992) 2:1
203 Brahams loc. cit..
132
The fetus exists only because of the
nourishment of the woman's body. The obligation
of the woman to continuously nourish the fetus
is absolute; that is, the mother is unable to
withdraw fetal access to the maternal
circulation until the pregnancy is terminated
or at term [ranging from 37 weeks to 42 weeks
gestation]. The newborn baby is, however,
exposed at birth to alternative methods of
nourishment. The woman is able to withdraw the
baby's access to breastmilk, and due to the
industrial adaptation of cow’s milk, give the
baby artificial formulae.
The obligation of the woman to provide correct
nourishment (uncontaminated by drugs such as
narcotics, alcohol or cigarettes), to the
fetus, has been argued for by many writers 204 205 206and is expanded on briefly later in this
Chapter.
Whether the nourishment is beneficial or
harmful, the fetus, like the newborn baby is
unable to prevent harms or make a claim for
correct nourishment. In the case of the fetus
the best results would be obtained if the
mother avoided drugs. In the case of the
newborn baby the best results would be obtained
if the mother chose breastfeeding.
204 Tanne, J.H. l991. ‘Jail for pregnant cocaine users in the US’. British Medical Journal. 303;6807 10:12 p 873.
205 Peacock, J.M., Bland, J.M., & Anderson, H.R. l991. ‘Cigarette smoking and birthweight: type of cigarette smoked and special threshold effect’. International Journal of Epidemiology. 20:2 June pp 405-412
206 Martin, T.R., Bracken, H.R. & Sloan, M. l992. ‘Cigarette, Alcohol and Coffee consumption and prematurity’. American Journal of Public Health. 82: 87-90
133
.41 Beneficence and non-maleficence
Because the midwife has to act to meet the
best interests of the baby and the mother,
the use of the principles of beneficence and
non-maleficence may sometimes provide
sufficient justification for overriding the
principle of respect for autonomy.
Beauchamp and Childress distinguish the
principles of beneficence and nonmaleficence
in the following way:
Non-maleficence; 1. One ought not to inflict evil or harm;. Beneficence; 2. One ought to prevent evil or harm 3. One ought to remove evil or harm 4. One ought to do or promote good.207
Balancing these principles while respecting
autonomy in order to achieve the best
outcome becomes complex when the mother
chooses to artificially feed her baby.
The midwife, when endeavouring to respect
the woman's autonomy, but wanting to avoid
the harms of giving artificial formulae to
the baby, must decide which of the these
action guiding principles, on balance, is
best. If the sum total of benefits falls on
the side of non-maleficence (avoiding harms)
then attempts to change the woman's mind
would be justified.
The principle of beneficence dictates that
one ought to promote or do good, but also
207 Beauchamp and Childress, op. cit., p 122-123
134
act to prevent harm. By successfully
persuading the woman to breastfeed and not
give formulae to the baby the midwife not
only promotes good but more importantly
removes harm from the baby. There is no
conflict.
The principle of non-maleficence (one ought
not to inflict harm) allows for inaction.
The midwife who refrains from feeding the
baby artificial formulae (in spite of a
request from the breastfeeding mother) is
refusing to inflict harm on the baby.
However, the mother then has to breastfeed
and may resent the baby for depriving her of
what she perceives to be a benefit ie. good
night’s sleep.
If the midwife considered that refusal (to
give the baby formulae) would inflict
emotional harm on the mother, then she may
feed the baby the formula, justifying her
action on the basis of avoiding emotional
harm to the woman. There would be no point
in suggesting that the mother give the
formula to the baby, as it would defeat the
purpose of the woman's desire to achieve a
good night's sleep.
Balancing benefits or harms against
alternative benefits or harms occurs when
the benefit to the mother does not coincide
with the benefit to the baby. This
balancing requires more than relying on
principles of beneficence, nonmaleficence or
autonomy to decide what is in the best
interests of both mother and baby.
.42 Utilitarianism
135
A Utilitarian or consequential view may lead
the midwife to consider that on balance
emotional harm to the mother is a lesser
harm than the potential physical harms to
the baby. The better action would be to try
to persuade the woman to breastfeed or for
the midwife to suggest the provision of
positive alternatives such as wet nursing or
human milk banking.
By using a consequentialist approach or
Utilitarian framework or doing what on
balance leads to the greatest benefits, an
argument for not harming the baby may be
put. It is difficult to say however, what
would produce the most benefit or happiness
for the baby in the long term, or
alternatively what, in the short term the
baby would prefer. Irrespective of what the
baby and parents want, it may be that, what
the baby in the long term would
intrinsically value, or subsequently consent
to, is the more important measure. In order
to objectively measure what the baby might
value in the long term, it is probably
better to choose values of health, or
freedom from pain, when minimising harms.
In a description about what values should be
considered as most desirable, most
utilitarians include health and freedom from
pain.208 Because, as I have already stated,
in determining utility for a baby,
preferences cannot be measured, I have
chosen health as a value which any
reasonable person would value.
208 Beauchamp and Childress, op. cit., pp 27-28
136
Before exploring some of the issues related
to contemporary baby nutrition, we should
note that left to nature, most babies would
be breast fed. Leaving babies to nature
means that (as a Swedish film demonstrates)
if a naked unwashed baby is placed on the
mother's naked body, it will instinctively
seek out the breast.209
The normal full-term human infant at birth
is equipped to breast-feed successfully.
Left to their own devices human infants will
follow an innate programme of pre-feeding
behaviour in the first hours after birth
that can include crawling from the mother's
abdomen to her breast. The baby has co-
ordinated hand-mouth activity and actively
searches for the nipple. The nipple has a
special odour [and deeper colour] and has
been measured to be 0.5 degrees centigrade
cooler than the skin around it.210 Finally the
mouth gapes widely and finally, latches well
to the breasts and feeds vigorously before
falling asleep. This latching on may take
from 5 minutes to 120-150 minutes after
delivery.211 212 Witnessing the behaviour of
this newborn baby might lead the observer to
assume that this baby could indicate a
preference, at least for breastmilk!
209 ALCA Source, (Personal Communication) Maureen Minchin 210 Odent, l992 op. cit., p 72 211 Widstrom, A.M. et. al. l987. ‘Gastric Suction in healthy newborn infants; effects on circulation and feeding behaviour.’ Acta Paediatr. Scand. 76: 566-572 212 Harris, H. l994 President of ALCA Personal Contact and video.
215 Kitzinger S & Simkin, P. l988. Episiotomy and the 2nd Stage of Labour. 2nd Ed. USA: Pennypress
216 Hofmeyr, G.J. et al. l991. ‘Companionship to modify the clinical birth environment: effects on progress and perceptions of labour and breastfeeding.’ British Journal of Obstetrics and Gynaecology 98: pp 756-764 cited in Kroeger M. l993. ‘Labour and Delivery practices: The 11th Step to Successful Breastfeeding.’ MIC op cit Vol II May 9-14 p 1023 -1037
138
adrenaline released when fear is present.
Fear was significantly reduced in the
presence of a midwife and the absence of
intervention. Newton hypothesises that this
inhibition is present in mammals to prevent
milk stealing. 217
In spite of what is thought to be natural or
what in the long term a child might value
some women may choose to give a bottle of
infant formula to a baby even when there is
a strong family history of asthma, diabetes
or other potentially fatal diseases.
Despite the woman's autonomous state, the
midwife should act to prevent harm to the
baby. The woman's own good physical or
mental, may not be sufficient reason to harm
the baby.
However, the mother may consider that loss
of income is a greater loss than harm to the
baby. The future harms to the baby may not
be easy to imagine while immediate loss of
for example income is concrete. Unless
employers can be persuaded to provide
facilities for breastfeeding women then in
current circumstances her decision is
justifiable.
It would be wrong if the mother, having been
informed about the harms of artificial
formulae and there was no other obstruction,
still persisted in giving the baby
artificial formulae. The baby is of equal
worth when considering our obligations not
to harm. Are the harms reasonably
foreseeable and if they are, what is the
217 Hofmeyr, loc cit.
139
moral responsibility of the woman in
avoiding harms to her baby?
.43 Parental Rights
The right of parents to make decisions for
their children is discussed at length by
Carson Strong in a paper about the rights of
deformed babies and their rights to live or
die. The arguments put in his discussion
about parental rights can be transferred to
the discussion about artificial feeding when
he claims:
This [parent's] right to decision making has limits, of course. When parental decisions are likely to result in harm to a child, the state may intervene, as in cases of treatment refusal on religious grounds.218
If the harms of artificial formulae are
sufficient to override the parents wishes,
state [government] intervention, in this
case would require a beneficent act to
prevent harm, rather than promote a
treatment.
Strong suggests `...that the interests of
the infant should take priority in these
treatment decisions’. 219
218 Strong C. l986. ‘The Principle `Patients Come First' and Its Implications for Parent Participation in Decisions’. in Weil W.B. and Benjamin, M.(Eds.). l986. Contemporary Issues in Fetal and Neonatal Medicine Ethical Issues at the Outset of Life. Melbourne: Blackwell Scientific Publications. p 189-190
219 Strong, op. cit., p 189
140
The woman is not just free to choose for
herself, as has already been stated, she has
a fundamental obligation not to harm the
baby. In one of Mill's well known position
statements about liberty, he suggests that
the only time a person can be forced to do
something against their will, is to prevent
harm to others.
... the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others [my italics] His own good either physical or moral, is not a sufficient warrant.220
As the moral dilemma is created by the
conflict between the woman's desire to feed
her baby artificial formulae and prevention
of harm to the baby, then who should decide
when power can be exercised over this woman?
When we return to John Stuart Mill's
classic statement about power over the
autonomy of others above, it supports
Strong’s view that there are limits to
family autonomy.
Mill would surely have included children in
these others. While Mill excluded children
from the benefits of liberty he did not
exclude them from protection against harm.
We are not speaking of children, ...Those who are still in a state to require being taken care of by others must be protected against their own actions as well as against external injury221
220 Mill, op. cit p 8
221 Mill, loc. cit.
141
O'Neill further reinforces the view that
children should be protected from harm when
she states that;
... although they [children] (unlike many other oppressed groups) cannot claim their rights for themselves, this is no reason for denying them their rights.222
As already outlined in Chapter One there is
ample evidence to support a position that
artificial formulae may contribute to the
high prevalence of life-shortening disease
in our society.223 224 225 There is, therefore,
a good case for the state acting to persuade
parents to support breastfeeding and prevent
harm to babies from artificial formulae.
It is for reasons of justice that the state
may need to intervene. That is, the harm to
a future population, resulting from
thousands of babies being given artificial
formulae, has broader implications for
society. Immeasurable costs to the health
of society from diseases such as eczema,
asthma and diabetes is one implication.
Economic costs to the National Health Scheme
in the UK are estimated at 68 million
English pounds per year due to gastro-
enteritis.
222 O'Neill, O. l988. Children's Rights and Children's Lives. Ethics. 98:4 pp 445-446
223 Cunningham, loc. cit. 224 Akre, (Ed.) l989. ‘Physiological Development of the Infant’. in Supplement to the Volume 67, l989, of the Bulletin of The World Health Organisation. ‘Infant Feeding the Physiological Basis’. Geneva: WHO p 63 Chapter 4
142
Pollution effects on the environment from
the equipment used to market formulae are
not usually included in the equation (883
million l6 ounce cans for milk powder were
sold in the USA in 1992) but is one hidden
factor worthy of note.226
The moral question is whether it is right
for the midwife to intervene when there is
likely to be emotional harm to the mother.
Are these emotional harms greater than the
potential for ill health? It could be
argued that although emotional harms are
significant, there are methods of overcoming
these harms, whereas potentially fatal
diseases are not so easily overcome.
Article 3 (1) of the U.N. Convention on the
Rights of the Child expresses the rights of
the child in the following way:-
in all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.227
Article 24 recognises the right of the child
to the enjoyment of the highest attainable
standard of health. One of the provisions
for the implementation of this right is:
225Minchin ,M. l987. Food for Thought. Sydney: Unwin Paperbacks
226Bird, L. l993. ‘TV Ads Boost Nestle’s Infant Formulas. Market Scan’ The Wall Street Journal. Mar 30 pp B1-B4 cited in ‘Baby Milk Action’ Update l994. 11(7) 13 227 United Nations l989. ‘The Convention on the Rights of the Child’. General Assembly of the United Nations. 20th November l989.
143
‘to ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of ...the advantages of breastfeeding,...’
This section of the Convention could be
interpreted as meaning that state
intervention to support a benefit such as
breastfeeding would be justified.
.44 Limits of coercion/Parental Rights
When a woman has been fully informed about
the risks of harm to her baby, but
nevertheless chooses to use formulae, what
should the midwife do?
The midwife could take steps to persuade the
woman to breastfeed such as arranging for
an expert lactation consultant [IBLC] or a
doctor who is a breastfeeding enthusiast, to
visit the woman to reinforce the credibility
of the midwife’s advice. Presuming that the
woman does not wish to knowingly harm her
baby, it may be reasonable to suggest
positive alternatives to artificial formulae
such as wetnursing or human milk from the
banking of other women’s milk, on the
grounds of minimising harms to the baby.
These alternatives are less harmful and may
be cheaper than artificial formula and could
be a means of enabling the woman to pursue a
career or relieve her of breastfeeding if
deep psychological problems are the cause of
her reluctance to breastfeed.
.45 Justifying Interference with Liberty
Now the woman to whom I refer may not desire
to feed her baby with breastmilk (her own or
any other woman’s). It would not be
144
appropriate to intervene as there is no way
you can force this woman to breastfeed
unless you tie her down. Seizing or tying
this woman up would be a serious
infringement of her liberty. Tying the
woman down would also be impractical as
surveillance alone would require a great
deal of time and money.
In Charleston, South Carolina, pregnant
women using cocaine are forced into
treatment and may even be jailed. If the
woman does not present for a programme of
treatment before 27 weeks gestation, she
will be indicted. The programme consists of
completing treatment for addiction and
antenatal care while incarcerated. The cost
(in the USA) of treating a baby addicted to
cocaine is $5,200 American. The American
Civil Liberties Union argues that this
forced treatment is:
paternalistic and strips pregnant women of their rights to bodily integrity and privacy and to refuse medical treatment.228
Arresting the woman in order to provide the
baby with breastmilk may be extreme, but it
is at least conceivable that a judge might
be convinced to jail women to prevent harm
to the newborn, in a similar way to the
previously mentioned South Carolina
judiciary.
Nevertheless the argument put by the
American Civil Liberties Union, on anti-
228Tanne, op. cit., p 873.
145
paternalistic grounds against incarcerating
women for cocaine addiction is strong.
If. as Brahams cited earlier (page 135)
states, the fetus must ‘take its mother as
if finds her’ then it may follow that the
newborn should take mother as it finds her.
It would, in my view be both wrong and
impossible to force a woman to breastfeed
her baby. The interference with liberty is
too drastic to be outweighed by possible,
but uncertain life-shortening harms to the
baby.
Pregnant women are strongly advised to avoid
socially acceptable drugs such as alcohol
and nicotine, but are not jailed if they
imbibe. The fetus who is exposed to parents
who drink excessive alcohol is likely to be
born mentally and physically retarded.
Fetal Alcohol Syndrome [FAS] is a well
recognised phenomenon of newborn babies
whose mothers drink excessively especially
in the first trimester. The baby is
characterised by microcephaly (small head
with limited ability for the brain to
expand) and lower than average development
of facial features. The baby suffers from
alcohol withdrawal at birth if the mother
continues to drink during the pregnancy and
is treated with sedation until delirium
tremens (commonly known as D T's) cease.229
In order to prevent this effect (in women at
risk for conceiving while overusing alcohol)
incarceration would be required before
229 Olds, op. cit., Glossary
146
conception or at least during the first
trimester before the brain develops!
A woman who is forced against her wishes to
breastfeed is more likely to be angry, and
resent those who restrict her freedom. The
extent of the power of the jailers is out of
proportion to the good achieved if the woman
breastfeeds. Also as the WHO recommends at
least six months exclusive breastfeeding the
cost of supervision and lodging would make
custodial breastfeeding impractical. The
woman may project her anger towards the
child.
It would be better if the woman was swayed
by reasons put by an expert. It is possible
to sway women or people generally, by
applying pressure through enlightened peer
groups or by the method described as the
Theory of Reasoned Action.
Icek Ajzen and Martin Fishbein, two American
professors of communication and psychology,
profer a theory of reasoned action which
they state:
can be applied to the problem of changing behaviour through persuasive communication... the ultimate determinants of any behaviour are behavioural beliefs concerning consequences and normative beliefs concerning the prescriptions of relevant others. To influence a persons behaviour ...it is necessary to change their primary beliefs.230
The primary belief may be that artificial
formulae is as good as breastmilk.
230 Ajzen, I., Fishbein, M. l980. Understanding Attitudes and Predicting Social Behaviour. New Jersey: Prentice-Hall pp 239-242 .
147
While yielding to persuasion may not occur
and acceptance of the information may have
little impact it was Azjen and Fishbein’s
finding that the discomfort created by a
message was sufficient for example, to
promote changes in the behaviour of
alcoholics.
The message about positive feedback when
alcoholics joined a recovery program had
less impact than giving negative impact for
failing to join a program. Similarly then
in the case of breastfeeding, giving
information about its benefits may have
little impact, but providing discomfort
about the negative effects of formulae
feeding might.
Frowning by midwives at women (as described
on page 9 of the first chapter) who chose
artificial formulae, may be justified on the
basis of causing discomfort.
The use of influence by high prestige,
powerful figures may result in easier ways
of enhancing breastfeeding practices or it
may just result in strong paternalistic
instruction. The influence of peer groups
may be stronger especially if that group is
met with frequently. If the peer group or
family, have a strongly held belief about
artificial feeding then their influence may
be greater than any paternalistic
instruction from a professional. Discomfort
created by being different may be a more
powerful factor in changing beliefs about
infant feeding.
148
The Baby Friendly Hospital Initiative
brochure published by UNICEF and WHO in
August l991 includes over thirty actions or
ideas to influence the community about
breastfeeding. These ideas include posting
and distributing the Ten Steps to Successful
Breastfeeding in schools churches companies
and places of employment.231 The unfreezing
process is included by suggesting women ask
prospective health carers or agencies if
they are baby friendly and to communicate
disapproval of marketing strategies to
formulae companies. The use of positive
reinforcement (praising those who follow the
Ten Steps) included in these ideas,
incorporates the precepts of refreezing.
Another question is whether parental rights
are greater than those of the newborn baby.
Can the woman who gives the artificial
formulae to her baby, (in spite of knowing
about foreseeable harms to her baby) be
231 The Ten Steps to Successful Breastfeeding. Every facility providing maternity services and care for newborn infants should: 1. Have a written breast-feeding [sic]policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breast-feeding. 4. Help mothers initiate breast-feeding within a half-hour of birth. 5. Show mothers how to breast-feed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice (sic) rooming-in allow mothers and infants to remain together 24 hours a day. 8. Encourage breast-feeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers to breast-feeding infants. 10 Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic. World Alliance for Breastfeeding Action [WABA] 1989 From: Protecting and Supporting Breast-feeding. The special Role of Maternity Services. A joint WHO/-UNICEF Statement, Published by the World Health Organization, 1211 Geneva 27, Switzerland, l989. Geneva UNICEF
149
compared with those women who smoke or drink
alcohol during pregnancy? Can the woman's
wishes to artificially feed be overridden in
the best interests of the baby?
Strong states that:
care and nurture of their children which includes basic needs such as food ....Parents are also given a great deal of discretion in proper ways of caring for their children, even though there is a great deal of diversity of opinion on what is the in our culture parents have a moral responsibility to provide for the best approach ...the autonomy of individuals is a value of great importance, and respect for autonomy requires that we respect the decisions of parents concerning family life...232
When the mother makes a decision about
feeding her baby artificial formula, she
probably believes she is acting
beneficently, that is, she is nourishing her
child. The decision to artificially feed
the baby however, is more likely to be based
on benefits to or avoiding harm to herself
than unknown perceived harms to the baby.
These benefits may include meeting work
commitments for monetary reward. While
Bundrock indicated that their were cost
benefits (approximately $500 to the woman
who breastfeeds) this amount would be
insufficient inducement to remain at home.
However the cost savings to the health
budget of a nation may be sufficient
inducement for a Government to provide
232 Strong, loc cit.
150
facilities for breastfeeding mothers in the
workplace.233
Avoiding harms may include emotional
harms such as embarrassment or deep
psychological harm. Physical harms such
as mastitis or breast abscess experienced
in a previous pregnancy are often cited
by women as a deterrent to repeating
breastfeeding. Because counsell-ing may
improve the former and better management
of breastfeeding prevent a repetition of
the latter the midwife should try to
dissuade the woman from artificially
feeding her baby.
.45 Justifying Interference with Liberty
While Strong, in an earlier statement
about the priority of infants in
treatment decisions, is referring to a
decision about providing life prolonging
treatment, he goes on to argue that
parents (and physicians) are the best
decision makers. The conflict between
what is right for the parents and what is
in the best interests of the infant,
identifies the need for some overriding
decision to be made when there is likely
to be evil produced to someone else.234
The example of giving or not giving
artificial formulae is not as extreme as
the life prolonging or life ceasing
decisions in Strong's example of a
deformed child, but is close to the issue
of the brain damage related to the boy in
233 Bundrock, loc. cit. 234 Strong, loc. cit.
151
a Jehovah's witness example describe
further on in this chapter.
The midwife should be able to intervene,
when the mother makes a decision to
artificially feed her baby, if there is
significant likelihood of damage or harm
to the baby.
If the woman values acting on the basis
of well-informed reasoning, then the
midwife is morally justified in
intervening by persuading her to breast
feed because formulae is likely to
irreparably harm her baby's development.
Compelling this woman to breastfeed may
be justified on the basis of preventing
harms to the baby. However, as the action
required to place this baby's health
above the woman's autonomy may involve
disproportionate action such as
incarceration or tying the woman down,
then her decision to artificially feed
the baby would have to be respected.
Mill 235 describes three kinds of
objections to the interference of the
state. In the first he suggests that it
is better for individuals to carry out
something in which they are personally
interested. This suggestion is congruent
with the principles of respecting
autonomy in decision making. This woman
is not personally interested in
breastfeeding, and although the state may
235 Mill, op. cit., p 98-99
152
wish it, incarceration is not a suitable
or just solution.
The second objection relates to a notion
which is congruent with the principles of
adult learning theory. Performing
something which even if not done well
will enhance their knowledge of subjects.
The woman may learn more if she
artificially feeds her baby and then
discovers that the baby is allergic to
the formulae. It might be through this
experiential learning that she is finally
convinced to try breastfeeding in order
to avoid harm even if only for future
children.
The third objection relates to the
subject of power. Mill suggests that the
most ‘cogent reasons for restricting
interference of government is the great
evil of adding unnecessarily to its
power’.236 Tying women down to breastfeed
or forcing them to breastfeed will lead
to an abuse of that power.
Paternalistic actions can be beneficial in
particular or unusual cases, such as giving
blood to save the life of the child of a
Jehovah's Witness. Strong goes on to state
that parents have a right to make decisions,
but with that right comes responsibility.
The right to decision making has limits
especially when parental decisions are
likely to result in harm to a child. The
state has intervened, in cases of treatment
refusal on religious grounds such as occurs
236 Mill, loc. cit.
153
in patients who are Jehovah's Witnesses and
who require a blood transfusion to avoid
brain damage or death.
Jehovah's Witnesses believe that taking
blood into one's body through the mouth or
veins is a violation of God's Law. Their
belief is so strong that, as they state: ‘if
we try to save our life, our soul, by
breaking God's law we will lose it [our
soul] everlastingly’.237
In a New Jersey case, Muhlenberg Hospital v
Patterson,
...a blood transfusion was ordered for a minor, (a Jehovah's Witness), because of the risk of permanent brain damage rather than death. ...The court ordered the operation and a transfusion stating that to delay the operation until the boy was old enough to decide, would cause harm. •
The outcome of this decision for the child
may be exclusion from the family and
religion. The emotional harms to the child
and the family may be so great that death
may have been preferred. ‘Death due to a
refusal to accept a blood transfusion is
ultimately equated with dying for one's
beliefs’.238 If the boy had not been given a
transfusion then the harm in his eyes may
have been less than being excluded from his
family.
237 Anderson, G.R. l983. ‘Medicine Vs. Religion: The case of Jehovah's Witnesses’. Health and Social Work. Vol No p 32
238Anderson, loc. cit.
• [320 A 2d 918 (N.Y. l971) See North Eastern Reporter Vol 278 N.E. 2d [St. Paul Minn: West Publishing Co.] 41. in Anderson G.R. l983 Medicine Vs. Religion The case of Jehovah’s Witnesses. Health and Social Work. pp 31-38
154
It could be said that women will suffer
severe emotional distress or depression as a
result of being made to feel inadequate for
artificially feeding the baby. As referred
to earlier women were frowned upon.
Ostracising women in this way would be one
form of coercion which could lead to
depression. What could be worse than
feeling ostracised however, may be an
unsettled crying baby suffering allergic
reactions from exposure to artificial
formulae. The unsettled crying of a
distressed baby may also lead to depression.
The subsequent sleepless nights, for many
months may outweigh the short term gain of
sleep in hospital when a midwife gave a
bottle of formula to the baby.
A woman who is forced to breastfeed may also
feel depressed. All three situations
(a) being ostracised, (b) a crying baby
suffering allergy and (c) being forced to
breastfeed, could lead to rejection of the
baby.
An analogy can be drawn here with the
emotional harm felt by the Jehovah’s Witness
parents who were directed by law to
surrender their child to the direction of
the medical profession. The belief that if
they receive blood they will risk eternal
damnation may affect their attitude towards
their son. It may be hard for some parents
to rationalise the involuntary nature of
this transfusion and may spiritually reject
the child.
155
5. Persuasion And Its Limits
Some beliefs are demonstrably false. If the
midwife or the woman believes that artificial
formulae is just as good as breast milk then
there may be a need for management strategies
or an approach which will help to change their
false belief. There may be justification on
the basis of beneficence or non-maleficence to
ensure that the non-autonomous (or ignorant)
woman is exposed to current information.
The midwife who educates the woman about
artificial formulae and breastfeeding has a
moral obligation to have current knowledge, and
be skilled in communicating this knowledge.
The midwife is in a position, because of her
close proximity with the birthing process, to
exert an influence over the vulnerable woman's
choice of infant nutrition. That is, the
midwife may use persuasive catch phrases such
as breast is best to persuade the woman to
initiate breastfeeding following delivery.
On the other hand the midwife is in a position
to coerce the woman not to breastfeed. She may
use other persuasive phrases such as a good
night's sleep, to influence the woman to leave
her baby in the nursery to be fed with
formulae. Also, some midwives avoid their
obligations by withholding or omitting
information about the harms of artificial
formulae.
Choosing someone who has charisma and
credibility, may help to influence a woman to
change her mind about feeding her baby with
infant formula, but as an experiment by J.
McCroskey demonstrated, the credibility of the
156
source had less bearing on outcome than strong
supportive evidence.239 The midwife (with or
without charisma) should be equipped with up to
date research-based knowledge. According to
Beauchamp and Childress `a person needs to be
convinced to believe in something through the
merit of reasons advanced by another person'. 240
According to Ajzen and Fishbein it was only
when there was minimal supportive evidence that
communicator credibility had any influence.
Ajzen and Fishbein also commented that
receivers with low self esteem yielded more to
forceful statements. But they gave an
explanation that these latter two conditions
did not influence a permanent change in
attitude.
It would be easy to understand then why
paternalistic instruction appears at least
superficially to work in the hospital setting.
The low breastfeeding rates at three months
referred to earlier could be a result of
paternalistic instruction forcefully given to
women of low self esteem. These instructions
may not have been supported by research-based
evidence and therefore failed to influence a
change in belief about the harms of artificial
formulae.
As described earlier by Ajzen and Fishbein
feelings of discomfort are more likely to
produce a change in beliefs. The pressure from
peer groups with whom they are in constant
contact may be a greater influence than the
occasional encounter with a professional.
239 Ajzen & Fishbein op cit p 223
240 Beauchamp and Childress op cit p 108
157
Persuasion is the weaker form of influence
according to Beauchamp and Childress. There
may be varying degrees of persuasion used. For
example when taking the history of a pregnant
woman who revealed (a) the death of a baby due
to Sudden Infant Death Syndrome (which has
links to formulae feeding) 241 242 or (b) a family
history of asthma,243 the midwife could use
evidence of an increased risk of harm to
persuade a reluctant woman to breastfeed.
But as Beauchamp & Childress state;
professionals are sometimes morally blameworthy if they do not attempt to persuade resistant patients to pursue treatments if they are medically essential244
Freedom to choose is limited when there is a
lack of knowledge about both methods of infant
nutrition. In order to explain the intricate
nature of the breast feeding mechanism and the
risks of artificial formulae the midwife needs
to ensure that the woman has substantial
understanding.
.51 Cultural forces and hormones.
If the woman has substantial understanding,
but still persists in giving her baby
241 Wood, C.B.S. & Walker-Smith, J.A. l981. MacKeith’s infant-feeding and feeding difficulties. 6th Edn. Edinburgh: Churchill Livingstone. p 105 in Cunningham op. cit., l985 p 15
242 Sudden Infant Death Foundation. Melbourne 243 Miskelly, F.G., Burr, M.L., Vaughan-Williams, E., Fehily, A.M., Butland, B.K., Merrett, T.G. l988 Infant feeding allergy Arch Dis Child. 63:388-93 in Cunningham, op. cit., l990. p 20
244Beauchamp, op. cit., p l09
158
artificial formulae, because she considers
that the risks to her own mental or physical
health are greater than harms to the baby,
should the midwife continue to seek to
persuade her to breast feed her baby?
I argue that the harms of artificial
formulae are so great that the midwife
should attempt to persuade the woman to use
other women's breastmilk for her infant's
nutrition. If a woman felt obliged to use
this method, to avoid harms to her baby,
there may be a risk that her self esteem
would be lowered. Her adequacy as a mother
may be challenged by partners, close
relatives and friends. The cost and
inconvenience of this option may be
prohibitive, and if it is, the woman may be
challenged to change her mind for the sake
of the baby. The discomfort felt may be
worse for the woman than the option of
breastfeeding her baby.
The extent to which the woman values health,
or the degree to which both physical and
mental health are prized, needs to be
considered before arguing on utilitarian
grounds. The potential for the baby to
suffer disease leading to early death (for
example from gastro-enteritis), is probably
a greater harm than the emotional harms to
the mother.
Also those women who successfully use
breastfeeding as a method of contraception
may be better off both in financial and
health status (as a result of not having to
purchase or imbibe synthetic chemicals).
There is also a reduced risk of cancer for
159
breastfeeding women and the potential to
improve other diseases such as diabetes
referred to in Chapter One.
In an example given in Chapter One, the
breastfeeding woman woke during the night
and asked to breastfeed her baby; the
midwife told the woman to go back to sleep,
and the midwife continued to artificially
feed the baby. The midwife overrode the
woman's autonomous wish to breastfeed.
The woman seemed powerless to prevent the
midwife from overriding the breastfeeding
woman's autonomous wish to exclusively
breastfeed thus causing harm to the baby.
Michel Odent a French obstetrician (well
known guru to most members of the
International Confederation of Midwives) is
in favour of non-intervention in the
birthing process. Odent profers an
explanation for the subservience of
breastfeeding women.
He suggests that the hormones oxytocin and
prolactin which are present in the breast
milk and in her system have a calming effect
on women making them sufficiently docile to
attend their babies needs. 245 The influence
of these hormones may explain the inability
to self-advocate of those distressed women
described in the Ministerial report.
Odent speculated on what might be the
cultural characteristics of a society where
245 Odent, M. l993. ‘A critique of The Anthropology of Breast-feeding’. Midwives Chronicle and Nursing Notes. November, p 456.
160
prolactin (the hormone responsible for milk
production) is in short supply. He states:
If the characteristics of a culture are shaped by the population's hormonal imbalance, my guess was that such a society would be highly aggressive and destructive, with little respect for the environment. This has been exactly the case in Icelandic society.246
Hastrup, a leading Danish anthropologist
made a detailed study of Icelandic women who
did not breastfeed their babies from
sometime in the l6th century to well into
the l9th century. The basic diet of these
infants was cow's milk or butterfat mixed
with fish. Hastrup proposed that one of the
reasons for not breastfeeding was tied in
with values about wealth related to milk
producing cows. The measure of wealth was
farm produce; cream and butter were tokens
of success.247
The reasons why a whole race would abandon
breastfeeding are obscure and seem
irrational. Eventually Icelandic women
returned to breastfeeding through the
educative influence of a physician. It would
seem that given rational reasons these women
were persuaded to return to breastfeeding.
So that education should be one of the
rational reasoned ways to influence change.
246 Odent, M. l992 The Nature of Birth & Breast-feeding. New York Greenwood Publishing Group
247 Hastrup, K. l992 ‘A Question of Reason: Breast-Feeding Patterns in Seventeenth-and Eighteenth-Century Iceland’. in Maher, V.(Ed.) l992. The Anthropology of Breast-feeding Oxford: Berg. pp 91 - 108
161
If the forces in a culture about profit are
enough to influence women to abandon
breastfeeding, then it could be postulated
that culturally induced embarrassment in
Australia (where women can be evicted from
public places for indecent exposure when
breastfeeding) is a major cause of women
abandoning breastfeeding.
.52 Embarrassment and Convenience
Embarrassment may be the outcome of a
cultural practice which leads many women to
prefer artificial feeding rather than any
other easily explained cause such as having
to work. Large numbers of women in the
workforce following childbearing have been
increasing only in the last 20 years. So
that return to the workforce does not easily
explain the high use of formulae immediately
following the second World War.
Embarrassment as a causal factor in women
abandoning breastfeeding at three months
needs further investigation but has been
cited as a reason in two studies.248 249 In
nearly all societies parts of a woman’s body
are hidden by clothing or restricted
posture. In some it is concealed in its
entirety and even threatened with death. In
Nigeria Posters denounce short skirts:
‘Long Leg is evil... kill corruption’. 250
248 Allison, L. l992. ‘Breastfeeding trends in New Zealand’. Nursing Newsline. 9:2-3 cited in Jackson, H. J. l994. ‘Promoting, Protecting and Supporting Breastfeeding in a bottle feeding culture; Do Women really have a choice’? in Proceedings Midwifery and the Community 3rd National Research Forum Abbotsford: LaTrobe University. 249 Tupling, H. l988. Breastfeeding: a new mother’s handbook. Sydney: Watermark Press p 31
250 Kitzinger, l987 op. cit., p l88
162
Evidence that Victorian hotel owners and a
West Australian bus driver and a New South
Wales magistrate are offended by
breastfeeding may be extrapolated to and
reflective of public attitudes. 251 252.
Although as Kitzinger suggests (Chapter One
page l9) it is about invasion of male
territory; a threat that woman is coming out
of her hidden place.
A deeply ingrained cultural belief in the
general population may be transposed to
those midwives who do not appear to actively
promote breastfeeding. Midwives are
recruited from the community and community
attitudes are probably reflected in the
attitudes of a majority of midwives.
In a previously cited work by Ellis, a study
done in Canada, by M. Beaudry and
L. Aucoine-Larade on 780 women, revealed
that women who chose artificial feeding
perceived convenience or compatability with
maternal lifestyle as the primary reason for
choice of infant nutrition.253 It appears
then, that it is the wishes or preferences
of the parents which are paramount.
If the mother makes a decision to
artificially feed, in order to go to work it
may be considered interference with family
251 Jinman,R and Scott, J. l993. ‘Breast-feeders take protest to court’. The Australian. May 20 l994 p 9 252 Wells, M. l994 ‘Cover those Breasts’ in Letters to the Editor The Australian. May 25 p 13 253 Beaudry, M & Aucoine-Larade,L. l989. ‘Who Breastfeeds in New Brunswick, When and Why?’ Canadian Journal of Public Health. 80 (May/June), 166-172
163
life to attempt to overturn this decision.
Some women may need to return to work, and
as our society rarely caters for
breastfeeding women in the work place, the
woman who has to give up work to breastfeed
may perceive this as an interruption to
family life. So that interferences with
parental decision making, which may cause
harm to families, should be avoided.
Unpaid maternity leave is supported by
predominantly male Trade Unions. Some male
Trade Unions members may have preferred
women to stay at home to breastfeed if, as
Kitzinger suggests, the invasion of the work
place reflects that woman is coming out of
her hidden place. Providing breastfeeding
facilities at work may be a beginning to
the, albeit sub-conscious, giving up of
power.
Kitzinger describes an incident in Ireland
when a union member breastfed her baby at a
Chapter meeting. At a subsequent meeting
male colleagues many of them fathers of
large families criticised her. Ribald
comments about the size of her ‘you know
whats’, Kitzinger comments, reflected the
tendency of these men to move the mother
category in to the category of tart.254
In a statement in June, l993, Hiroshi
Nakajima, Director General of WHO said
'working outside the home and breastfeeding
are compatible when a mother has the support
of her family and her employer'. He also
suggests that employers should promote
254 Kitzinger, op. cit., p 189
164
better facilities for breastfeeding mothers
in the workplace and that there needs to be
a change in attitude by colleagues in the
work place.255
There would be no need to interfere with
family life if these structures, such as
time out to breastfeed and creches for the
children of breastfeeding women, were
available. The harms would need to bad
enough not only to the baby, but to a wider
society if society were to agree to having
these support systems.
Mill includes in his discussion about
objections to government interference the
idea of;
taking them out of the narrow circle of personal and family selfishness, and accustoming them to the comprehension of joint interests...the management of joint concerns - habituating them to act from public or semi-public notices and their conduct by aims which unite...256'
Involving the community or taking them out of
the narrow circle of personal and family
selfishness and accustoming them to joint
interests is outlined in the following pages in
a discussion about the Baby Friendly Hospital
Initiative. [BFHI].
255 Uniting Church of Australia l993. ‘Mother-Friendly Workplaces’ Baby Milk Action: Update. St James, NSW: Social Responsibility and Justice Committee for the Assembly 11:7 p 10 256 Mill, op. cit., p.98,99
165
The BFHI operates by first of all challenging
the way in which current practice occurs. In
the BFHI brochure an outline of longer-term
strategies for achieving a baby friendly world
is described.
The Ten Steps to Successful Breastfeeding are
the criteria by which hospitals are judged.
Ensuring the maternity centres practise all of
these is the role of an accreditation team
invited in by interested hospitals.
When some out of date midwives first hear these
instructions there may be a great deal of anger
and confusion. Some of these criteria
challenge deeply held beliefs of some midwives
particularly in relation to complementary
feedings, nursery care and scheduled feeding.
The involvement of women in completing a
questionnaire which asks them to answer the
question ‘How does your Neighbourhood
Hospital/Health Facility Measure Up?’ may help
to preserve a degree of autonomy for the woman.
The questionnaire involves the woman in
answering l7 prescribed questions related to
successful breastfeeding. These completed forms
are returned directly to the hospital
administration, by the woman. A double-
barrelled effect is that the hospital and the
staff’s roles are reversed and are now
accountable to the women in their care for
breastfeeding management. Previous quality
assurance evaluations primarily related to the
bland questions about noise, warmth of the room
and the quality of meals. The employer and the
midwives may receive negative feedback from
these women if they do not adapt to the ten
steps.
166
Mitcham and District Hospital was the first
Victorian private hospital to receive Baby
Friendly status in Victoria The Royal Womens
Hospital, a major Melbourne teaching hospital
failed on the first attempt in l993. The
discomfort created because its prestige was
dented caused a change in its behaviour. After
a year of hard work in November l994 its
prestige in relation to breastfeeding had been
restored. The Royal Womens Hospital, a major
Melbourne Teaching Hospital is now the first
teaching hospital in Australia to be granted
this status.
Both of these hospitals had employed a
lactation consultant midwife (IBLC) for a
number of years. The Board of Mitcham and
District Hospital replied positively to an
invitation by me on behalf of the Midwives
Action Group to apply for accreditation with
UNICEF as a BFHI in l991. This hospital had
already established a reputation at the
forefront of breastfeeding so that there was
very little need to change their practice. The
current number of applications for
accreditation is increasing according to the
midwife convenor of the Victorian Branch of
UNICEF Lisa Donahue.
Conclusion Throughout this Chapter an attempt has been
made to address the midwives’ obligations to
the mother and baby - a double entity. The
midwife and her obligations to act in the
interests of both mother and baby involved
arguing a case on utilitarian grounds to
provide what on balance would be in their best
interests. In order for the midwife to be able
167
to carry out her professional role it is
imperative that her knowledge is current.
Because it could be demonstrated that
breastmilk is the most beneficial nutrition for
the baby and has health benefits for the mother
the midwife is obliged for professional and
moral reasons to persuade the woman to
breastfeed her baby.
The midwife is also obliged to support those
women who choose to breastfeed and provide her
with up to date information. Because the up to
date midwife is aware of the harms to
breastfeeding of giving any supplementary or
complementary feeding, the midwife is obliged
to prevent and refrain from giving these to the
baby of any woman who wishes to exclusively
breastfeed. This midwife also is obliged to
promote change in her out of date colleagues.
The case to support this contention was easy to
present using the swimmer example given by
Kuhse and Singer.
Changing out of date midwives involves using
many strategies and some of those have been
included in this chapter. Change agents
included Azjen and Fishbein’s Theory of
Reasoned Action or Lewin’s unfreezing, freezing
model. The use of a Lactation plan introduces
the idea of women being involved in determining
and controlling, what happens to them and may
assist in circumventing the paternalistic
mistaken views of some midwives..
The more difficult case was arguing that a
woman who chose to artificially feed her baby
168
should be dissuaded from doing so and persuaded
to breastfeed.
The result of acting to respect this woman’s
autonomy is that the midwife needs to support
that woman’s decision to feed her newborn baby
with artificial formulae. But I argued that in
order to respect that woman’s autonomy the
midwife must ensure that the woman has
substantial understanding of the harms of
artificial formulae. Unless the woman receives
this information and has a substantial
understanding of this information then the
woman’s decision is based on limited knowledge.
In order to avoid foreseeable harms to the baby
I have argued that the midwife is obliged to
inform the woman of these harms. Some would
argue that this would make the woman feel
guilty, but I believe that to withhold this
information on the basis of what after all is
an assumption by the midwife is not
justifiable. Withholding information because
someone may feel guilty is making a decision
for someone else and may reflect a personality
trait on the midwives’ part that could affect
objectivity.257 In order to avoid paternalistic
assumptions the midwife should ask the woman
how she feels.
These guilt feelings while they may lead to
depression can be resolved through counselling,
while the demonstrable harms of giving
artificial formulae are not so easily reversed.
Lewin’s model of change or Azjen and Fishbein’s
theory of reasoned action supports my view that
257 Walker, B. l994. ‘Double Entity/Double Jeopardy’ in the Proceedings Midwifery and the Community 3rd National Research Forum Abbotsford Campus: LaTrobe University .October, l994 p l87
169
before a change in beliefs can be achieved a
sense of discomfort should be felt. If change
can be achieved based on negative appeal the
harms of artificial formulae should be clearly
described.
An argument on Utilitarian grounds was given
that on balance the harms to the baby from
artificial formulae are greater than any guilt
driven emotional harms to the woman. If this
sense of discomfort can be perceived to have
worse negative consequences than the discomfort
of breastfeeding then a change in behaviour may
be achieved by perceptions about preferred
consequences.
Regardless of any explanation about the harms
to the baby of artificial formulae, some women
for reasons known only to themselves still
prefer to artificially feed. I have
endeavoured to profer various explanations for
this preference which included notions of
deeply held beliefs influenced by religion
cultural beliefs, men, power, sexuality and
industrial formulae companies.
The limitations of parents to make decisions
was also explored and it was demonstrated by
the use of the example of Jehovah’s witnesses
that the wishes of parents could be overridden
by a higher authority (the law) if it meant
harm (brain damage or death) to the child. A
case of justified paternalism. Although some
women have been incarcerated to protect the
rights of the fetus from injury due to cocaine,
this action has been labelled unjustified
strong paternalism. The incarceration of a
breastfeeding woman to protect a baby from the
harms of artificial formulae (which are not
170
immediately life threatening) is not only
impractical but also unjustified strong
paternalism.
In order to justify persuading the woman to
breastfeed an argument was put, about the
baby’s right to be exclusively breastfed based
on the principles of beneficence and non-
maleficence. That is the benefits of breastmilk
and avoiding the harms of giving artificial
formulae to the baby. To satisfy these
principles means overriding the autonomy of the
woman if she persists in wishing to breastfeed.
If the woman believed that the harms of, for
example not being able to work, precluded her
from breastfeeding then in the interest of
avoiding harms to the baby alternatives such as
human milk banking and wet nursing were
suggested. Although both of these options are
currently becoming more readily available they
may not yet be practical. The woman however,
has a choice which does not involve tying her
down. Longer term solutions to options in the
workplace require intense lobbying and a
commitment from the community.
Even if the woman’s decision making abilities
were improved by giving her substantial
understanding about the harms of artificial
feeding, and she still persisted in her wish to
artificially feed her baby then there is very
little more can be done. Tying this woman down
would be impractical and unjustified as the
baby is not at risk of death. The situation
where the patient refused an injection was
different, restraining this person down to give
an injection is justified on the basis of his
171
reduced ability to reason and the consequences
of death.
The idea of a Lactation Care Plan as outlined
in this chapter assists the midwife in
assessing the woman’s health status and her
beliefs. Such a plan not only allows the woman
choices but should enhance the woman’s autonomy
by giving her the opportunity to record her
preferences and explain her beliefs.
According to Ajzen and Fishbein, in order to
influence a person’s behaviour it is necessary
to identify and change if necessary, these
primary beliefs. The primary belief may be
that artificial formulae is as good as
breastmilk.
The idea of signing a consent form which
outlines the harms of artificial formulae prior
to giving consent for the baby to receive
formulae not only protects the health worker
from future liability but may result in
producing a sense of discomfort in the woman.
So by creating discomfort or unfreezing the
behaviour a previously reluctant woman may be
persuaded to breastfeed. Because the health of
future babies and women can be improved by
exclusive breastfeeding I believe that it is
important to try to improve the understanding
of a larger population through democratic
means.
As recommended by the NH & MRC in Chapter one
these democratic means included formal and
informal education in schools and the
community. By encouraging more women to
breastfeed in the workplace, in public and even
172
in the media, better role models are provided.
Desensitisation to embarrassment may result.
I am confident also that the Baby Friendly
Hospital Initiative will provide some of that
means for midwives and hospitals to change
their out of date practices.
Other means of persuading women to breastfeed,
as the WHO/UNICEF joint statement suggests,
should be through an approach aimed at the
community. I believe Mill made this same
suggestion when he urged ‘society to take them
out of the narrow circle of personal and family
selfishness’. The health and the baby and the
woman and society are the joint interests when
he states ‘accustom them to the comprehension
of joint interests’ and the BFHI is
encapsulated in the statement ‘habituating them
to act from public or semi-public notices and
their conduct by aims which unite’.
The next step in the change theory approach is
that of freezing the behaviour. This includes
praising and affirming positive behaviours once
they are achieved. The reward of a contented
baby free from persistent illness is one such
reward. The awarding of the Baby Friendly
Hospital Initiative [BFHI] approval to the two
previously mentioned hospitals is likely to
prevent a return to habits which compromised
the autonomy of women as described in the
Ministerial Report of Birthing Services.
173
BIBLIOGRAPHY
______________Leading Article. l879. ‘Trained Nurses’ Australian Medical Journal n.s. 1. p 286 [ACMI] Australian College of Midwives Incorporated. l988 ‘Mead Johnson Advertisement’ ACMI Journal. 12:1 2.2 Back Cover [ACMI] Australian College of Midwives Incorporated. l989. Standards for the Practice of Midwifery. pp 7,8 15,19 Adcock, W, Bayliss, U., Butler, M., Hayes, P., Woolston, H. and Sparrow, P l984. With Courage and Devotion. A History of Midwifery in New South Wales. Sydney: p 25 cited in Thearle, M.J. & Gregory, H, circa l984 Childbirth by Choice - Midwifery in Queensland from Pre-History to the l930’s. South Brisbane: Mater Misericordiae Children’s Hospital and Queensland: Department of Child Health University of Queensland P 7 Akre (Ed.) l989. ‘Physiological Development of the Infant’. in Supplement to the Volume 67, l989, of the Bulletin of The World Health Organisation: Infant Feeding the Physiological Basis. Geneva: WHO. Allison, L. l992. ‘Breastfeeding trends in New Zealand’. Nursing Newsline. 9:2-3 cited in Jackson H. J. l994 ‘Promoting, Protecting and Supporting Breastfeeding in a bottle feeding culture; Do Women Really Have a Choice?’ in Proceedings: Midwifery and the Community: 3rd National Research Forum. Abbotsford: LaTrobe University Anderson, G.R. l983. ‘Medicine Vs. Religion: The case of Jehovah's Witnesses.’ Health and Social Work. Vol? No.? p 32 Australian Lactation Consultants Association [ALCA] Source, (Personal Communication Maureen Minchin) Ajzen, I.,Fishbein M. l980. Understanding Attitudes and Predicting Social Behaviour. New Jersey: Prentice-Hall
Barnes, F. l898 Chavasse’s Advice to a Wife. (l4th Edn. rev.) London: L J & A Churchill Beauchamp, T.L. & Childress, J.F. l989. Principles of Biomedical Ethics. New York: Oxford University Press Bennett, V.R. & Brown, l989. Textbook for Midwives. (llth Edition). Melbourne: Churchill Livingstone Beaudry, M & Aucoine-Larade,L. l989. Who Breastfeeds in New Brunswick, When and Why? Canadian Journal of Public Health. 80 (May/June), 166-172 Bird, L. l993. TV Ads Boost Nestle’s Infant Formulas. Market Scan. The Wall Street Journal. Mar 30 pp B1-B4 cited in Baby Milk Action: Update 11(7) 13 Black, G. (Ed.) l888. The Young Wife’s Advice Book The Long Life Series. (6th Ed.) London: Ward Lock & Co
174
Bohane, T. l991. Cow's milk is risky for babies Australian Doctor. July, 12 p 2 Bolton, R. l991. People Skills How to Assert Yourself, Listen to Others, and Resolve Conflicts. Australia: Simon Schuster. Parts One and Two Borham, G. l994. ‘Midwives set back in Bid for Autonomy’. The Age. 19/11/94 p 9 Britt K. l993. Personal Communication Community Midwife specialising in care of adolescent pregnant women at Ringwood: ‘Starting Out’. Brahams, D. l991. ‘Australian mother sued by child in utero’. The Lancet. vol 338 no 8766 l4 September pp 687-688 in MIDRS: Midwifery Digest (Mar l992) 2:1 Brooten, D., Brown, L, Hollingsworth, A Tanis, J. Bakewell-Sachs, S l985. ‘Breast-Milk Jaundice’. Journal of Obstetric Gynaecological and Neonatal Nursing. May/June Vol 14:3. 220-223
Bundrock, V. l992. ’The Economic Benefits of Breastfeeding in Australia’. in Topics in Breastfeeding: Set IV. October, l992.. Nunawading: NMAA: Lactation Resource Centre. Campbell, N. l989. Royal Children’s Hospital Personal Contact Commiso, K. l992. President of ALCA Personal Communication. Cunningham, A.S. l986. Breastfeeding, Bottle feeding & Illness An annotated Bibliography. l986.LRC Series: 1 Colombia University. Permission granted for reproduction to Australia: ALMA publications and the Nursing Mothers Association of Australia Cunningham, A.S. l990. Breastfeeding and Bottle feeding & Illness An annotated Bibliography. LRC Series: 2. Colombia University. Permission granted for reproduction to Australia: ALMA publications and the Nursing Mothers Association of Australia Danner, S.C. l992. ‘Breastfeeding the Infant with a Cleft Defect’. NAACOG’s Clinical Issues. 3(4) 634-639 Davis, A. & George, J. l988. States of Health Health and Illness in Australia. Sydney: Harper and Row Duncan, B. Chifman, R.B. Corrigan J.J. Jr et al: l985. Iron and the exclusively breast-fed infant from birth to six months. J. Paediatr Gastroenterol Nutr. 4: 421-425 Ellis, D & Hewat R. l993. ‘Factors Related to the Duration of Breastfeeding: How the Midwife Can Enhance.’ in the Proceedings International Confederation of Midwives: 23rd International Congress: Midwives Hear the Heartbeat of the Future. Vancouver: (ICM). Volume II p 628 Faden, R.R. & Beauchamp, T.L. l986. A History and Theory of Informed Consent. New York: Oxford University Press.
175
Farrer H. l990. Maternity Care. (2nd Edition). Melbourne: Churchill Livingstone. Fildes, V. l986. Breasts Bottles and Babies. Edinburgh: Edinburgh University Press Fildes, V. l988. Wet Nursing: A History from Antiquity to the Present. Oxford: Basil Blackwood Gillon, R. l986. Philosophical Medical Ethics. Brisbane: John Wiley & Sons Hagger, J. l976. Australian Colonial Medicine Melbourne: Rigby p 118 Hardyment, C. l983. Dream Babies. England: Oxford Harris, A. l994 President ALCA Melbourne Personal Communication. Hastrup, K. ‘A Question of Reason: Breast-Feeding Patterns in Seventeenth-and Eighteenth-Century Iceland’ in Maher, V.(Ed.) l992. The Anthropology of Breast-feeding. Oxford: Berg pp 91 - 108 [H&CS] Health and Community Services. l994. Promoting Breastfeeding: Victorian Breastfeeding Guidelines. Melbourne: Victorian Government Publication [HDV] Health Department of Victoria. l990. Ministerial Review of Birthing Services: Having a Baby in Victoria. Melbourne: Womens' Health Unit. Hofmeyr, G.J. et al. l991. Companionship to modify the clinical birth environment: effects on progress and perceptions of labour and breastfeeding. British Journal of Obstetrics and Gynaecology. 98: pp 756-764 cited in Kroeger, M. l993. ‘Labour and Delivery Practices: The 11th Step to Successful Breastfeeding.’ in the Proceedings: International Confederation of Midwives. 23rd International Congress. Vol 11 May 9-14 pp 1023-1037.. Inch, S. l987. Meeting Report. 'Difficulties with breastfeeding: midwives in disarray' Journal of the Royal Society of Medicine. Jan; 80: pp 53-57. [ICM] International Confederation of Midwives (l976) Definition of A Midwife Accepted by the World Health Organisation [WHO] Jinman,R and Scott, J. l993 ‘Breast-feeders take protest to court.’ The Australian. May 20 l994 p 9 Johnson, T. l972. Professions and Power. Sydney: McMillan.
Kalisch, P. (Professor of History and Politics of Nursing at the University of Michigan, School of Nursing Ann Arbor).et.al. l981. ‘Louyse Bourgeois and The Emergence of Modern Midwifery.’ Journal of Nurse-Midwifery. Vol 26, No 4. July/August pp 3 Keyser, P.K. l992. From angels to advocates: The Concept of Virtue in Nursing Ethics from 1870 to 1980. Michigan: U.M.I.
176
Kitzinger, S (Ed.) l991 The Midwife Challenge. London : Pandora pp 94-95
Kitzinger, S. l987. The Experience of Breastfeeding. Middlesex: Penguin Kitzinger S & Simkin, P. l988. Episiotomy and the 2nd Stage of Labour. 2nd Ed. USA; Pennypress Kroeger M. l993. Labour and Delivery practices: The 11th Step to Successful Breastfeeding. ICM( see Ellis Hofmeyer) op cit. Vol II May 9-14 p 1023 -1037 Kuhse, H. & Singer, P. l985. Should the Baby Live? Oxford: Oxford University Press Lang, S. 1997 Breastfeeding Special Care Babies. London: Baillier Tindall Lawrence, R. A. l994. Breast Feeding: A Guide for the Medical Profession. 4th Edition. St. Louis: CV Mosby Lewinski, C. l992. ‘Nurses' knowledge of breastfeeding in a clinical setting.’ J. Hum Lact. 8 (3) 142-48 cited in Update l1,(10) p 9 Love, W. 1893. ‘Records of the Lady Bowen Hospital.’ Australasian Gazette. 13 p 145
Lucas A & Cole, T.J. l990. ‘Medical Science: Breast Milk and Neonatal Enterocolitis.’ The Lancet.vol 336 Dec 22/29 p 1519 Maher, V.(Ed.) l992. The Anthropology of Breastfeeding. Oxford/Providence: Berg Mair, J. l991. ‘Foetal Life and a Legal Duty of Care.’ ACMI Journal. Dec P 13 Martin, T.R., Bracken, H.R. & Sloan, M. l992. ‘Cigarette, Alcohol and Coffee consumption and prematurity.’ American Journal of Public Health. 82: 87-90 McKenna, J. l993. ‘Rethinking Healthy Infant Sleep.’ MIDRS: Midwifery Digest. (Sep l993) 3:3 Mill, J.S. l948. On Liberty and Considerations on Representative Government. McCallum R.B. (Ed.) Oxford: Basil Blackwell Minchin, M l985. Breastfeeding Matters. Alfredton, Vic: Alma Publications and Allen and Unwin Minchin, M. l987. Food for Thought Sydney: Unwin Paperbacks Motohara, K. et. al. l990. ‘Oral supplementation of Vitamin K for pregnant women and effects on levels of [plasma absence] in the neonate.’ Journal of Paediatr. Nutr. July: 11(1):32-6 Miskelly, F.G., Burr, M.L., Vaughan-Williams, E.,Fehily, A.M., Butland, B.K., Merrett, T.G. l988 ‘Infant feeding
177
Allergy.’ Arch Dis Child. 63:388-93 in Cunningham op cit. l990 p 20 Myles, M. l961. Textbook for Midwives 4th Edition. Edinburgh: E.S. Livingstone. National Health & Medical Research Council, l993. Background to the Statement and Interim Recommendations of Vitamin K prophylaxis in Infancy 16/1/93 Unpublished National Health and Medical Research Council [NH&MRC] l984. Guidelines on Implementation of WHO International Code of Marketing of Breast-Milk Substitutes [artificial formulae] Canberra; Commonwealth of Australia pp 1,2,6,7 Newton, M, & Newton, N.R. l948. The Let-Down Reflex in Human Lactation The Journal of Paediatrics Vol 33:5 July-December. St Louis: C.V. Mosby Company pp 698-704. cited in Newton, N with Newton, M. et. al l987. (Rev l990). Newton on Breastfeeding: Reproduction of Early Classic Works. Seattle, Washington: Birth and Life Bookstore. Newton, M & Newton, N. l962. ‘The Normal Course and Management of Lactation.’ Clinical Obstetrics and Gynaecology.’ Vol 5:1 Hoeber: Medical Division of Harper and Row Publishers March pp 44-63 Nisbet, W.N. l891. ‘The Education of Midwives.’ Australasian Medical Gazette. 10: p 270 Odent, M. l992. The Nature of Birth and Breast-feeding. Westport Connecticut: Bergin & Garvey Odent, M. l993. A critique of The Anthropology of Breast-feeding. Midwives Chronicle and Nursing Notes. November, p 456. Odent, M. l993. A critique of The Anthropology of Breast-feeding. Midwives Chronicle and Nursing Notes. November, p 456. Palmer, G. l988. The Politics of Breastfeeding. London: Pandora. Olds, S. London, M.L. Ladewig, P.W. l992. Maternal Newborn Nursing. (4th Edition). Sydney: Addison-Wesley Peacock, J.M., Bland, J.M., & Anderson, H.R. l991. ‘Cigarette smoking and birthweight: type of cigarette smoked and special threshold effect.’ International Journal of Epidemiology. 20:2 June pp 405-412 Peaker, M.P., Wilde, C.J., l987. ‘Milk secretion: autocrine control.’ News in Physiological Sciences [NIPS] 2: pp 124-126 cited in H&CS Promoting Breastfeeding Victorian Breastfeeding Guidelines. Melbourne: Victorian Government p 10 Pensabene, T.S. l980. The Rise of the Medical Practitioner in Victoria. Health Research Project: Research Monograph 2. Canberra: Australian National University.
178
Prentice, A. et. al. l989. ‘Evidence for local feedback control of human milk secretion.’ Biochemical Soc Trans l7: pp 122-123 cited in Health & Community Services [H&CS]. l994. Promoting Breastfeeding Victorian Breastfeeding Guidelines. Melbourne: Victorian Government p 10 Priestley S l986. Bush Nursing in Victoria: 1910-1985. Sydney: Lothian Publishing Co Pty. Ltd. in conjunction with Victorian Bush Nursing Association Renfrew, M., Fisher, C., Arms, S l990. Bestfeeding; Getting Breastfeeding Right For You. Berkeley: Celestial Arts.
Riordan, J & Auerbach, K.C. l993. Breastfeeding and Human Lactation. Boston: Jones and Bartlett Royal College of Midwives [RCM]. l991. Successful Breastfeeding. New York: Churchill Livingstone Russell, C & Schofield. T. l987. Where it Hurts: An Introduction to Sociology for Health Workers. Sydney: Allen & Unwen Sherr, I. l991. HIV and AIDS in Mothers and Babies. Carlton: Blackwell Scientific Publications. Short, R.V. l984. ‘Breast Feeding: Its contraceptive effect is increasing forgotten in the worldwide trend toward bottle feeding. In many developing nations the result is a rise in the rate of population growth and poorer infant health.’ Scientific American. April. Vol. 250 No. 4 p 23 Singer, P. l979. Practical Ethics Cambridge: Cambridge University Press pp 168 ff cited in Beauchamp, T. and Childress, J.l989. Principles of Biomedical Ethics. New York: Oxford University Press Smibert, J. l988. ‘A History of breastfeeding: With particular reference to the influence of N.M.A.A. in Victoria.’ Breastfeeding Review. 12:5 pp 24-20 Smith, J.A. & Ross W.D. (Eds.) l910. Aristotle, The Works of Aristotle. vol. 4: Historia animalium ed.Oxford in Fildes, V. l988. Wet nursing: A History from Antiquity to the Present. New York: Basil Blackwell p 9 Spitz D.(Ed.) l975. On Liberty: John Stuart Mill: Annotated Text Sources and Background Criticism. New York: W.W. Norton & Company Stewart, D. l992. ‘Why I’m a bottle-feeding mum.’ February Soapbox The Australian Women’s Weekly. Sydney: ACP Publishing Ltd. Stoner, J.A. Collins, R.R. and Yetton, l985. Management in Australia. New Jersey: Prentice-Hall. Stuart, A,M. l982. Every time she woke up my Heart sank. Nursing Mirror Vol ? No? p 64 Strong C. The Principle `Patients Come First and Its Implications for Parent Participation in Decisions.’ in
179
Weil W.B. and Benjamin, M.(Eds.) l986. Contemporary Issues in Fetal and Neonatal Medicine: Ethical Issues at the Outset of Life. Melbourne: Blackwell Scientific Publications p 189-190
Tanne, J.H. l991. ‘Jail for pregnant cocaine users in the US.’ British Medical Journal. 303;6807 10:12 p 873 Tinkle, M & Amaya, M & Tamayo, O. l992. ‘HIV Disease and Pregnancy.’ Journal of Obstetrics, Gynaecology and Neonatal Nursing. 21 (2): p 108 Thompson R. l994. Melbourne Midwifery Services Personal communication. Tippett. C. l993. Copy of Fascimile l5/11/93 to Minister for Health, M. Tehan held by Midwives Action Group [MAG] Australian Nurses Federation [ANF] (Victorian Branch) Towler J. & Butler-Manuel, R. l980. Modern Obstetrics for Student Midwives. London: Lloyd-Luke (Medical Books) Ltd. pp 2-3 Tunnessen, W.W. Jr. Orski F.A. 1991 ‘Consequences of starting whole cow milk at 6 months of age.’ J. Pediatr. l987: 111: 813- 816 ‘Meeting the iron needs of infants and young children: an update. Nutrition Committee, Canadian Paediatric Society’ in Canadian Medical Association Journal. l991: 144 (11) pp 1452, 1453. Tupling H. l988. Breastfeeding a new mother’s handbook Sydney: Watermark Press. UNICEF Australia. l992. Baby Friendly Hospital Initiative. Melbourne: Australian Committee for UNICEF Ltd.: United Nations Children’s Fund United Nations l989. The Convention on the Rights of the Child General Assembly of the United Nations 20th November l989. Uniting Church of Australia l993. Mother-Friendly Workplaces Baby Milk Action Update. St James, NSW: Social Responsibility and Justice Committee for the Assembly 11:7 p 10 Victorian Government l993. Annual Report of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity Incorporating the Survey of Perinatal Deaths. Melbourne; Victorian Perinatal Unit. Victorian Government l983. Midwives Regulations: Health Act l958 Waldenstrom, U & Swenson, A. l992. ‘ Rooming-in at night in the Postpartum Ward.’ Midwifery. UK: Longman Ltd. 7:82-89 Walker, B. l986. Survey of antenatal women's expectations, and postnatal women's actual patterns of sleep in the postnatal period. Melbourne: Mercy Hospital for Women. Unpublished Walker, B. l994. ‘Double Entity/Double Jeopardy’ in the Proceedings: Midwifery and the Community: 3rd National Research Forum. Abbotsford Campus: LaTrobe University October, l994 p l87
180
Wells, M. l994. ‘Cover those Breasts. Letters to the Editor.’ The Australian. May 25 p 13 Widstrom, A.M. et. al. l987. ‘Gastric Suction in healthy newborn infants; effects on circulation and feeding behaviour.’ Acta Paediatr. Scand. 76: 566-572 Wilkes, G.A. l982. Collins English Dictionary. Sydney: Collins. Willis,I. l983. Medical Dominance: The Division of Labour in Australian Health Care Sydney: George Allen & Unwin Wood, C.B.S. & Walker-Smith, J.A. l981. MacKeith’s infant-feeding and feeding difficulties. (6th Edn.) Edinburgh. in Cunningham, op. cit. l986 p 15
Woodward, D.R, Rees, B., Boon, J.A. l989. 'Human milk fat content: within-feed variation.’ Early Human Development. l9: 39-46
Woolridge, M.W., Baum, F.,M. Drewett, R.,F. l982. 'Individual patterns of milk intake at a feed in breast-fed babies' Early Human Development. 6: pp 265-272
World Alliance for Breastfeeding Action [WABA] 1989 From: Protecting and Supporting Breast-feeding. The special Role of Maternity Services. A joint WHO/-UNICEF Statement, Published by the World Health Organization, 1211 Geneva 27, Switzerland, l989. Geneva UNICEF
World Health Organization. l981. International Code of Marketing of Breast-milk Substitutes WHO/MCH/90.1 (Annex 2 p.47 )
Young, R. l986. Personal Autonomy: Beyond Negative and Positive Liberty. London: Croom Helm
